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Friday, December 05, 2008

I just finished reading Homebirth in the Hospital: Integrating Natural Childbirth with Modern Medicine by Stacey Marie Kerr, a family practice physician. Kerr has an unusual background for a medical doctor; she lived for several years on The Farm, gave birth to her first baby in a birthing clinic and her second at home, and then entered medical school in her mid-30s. She strongly supports the midwifery model of care in a hospital setting. Her book explains more about her approach to birth, which she calls "integrative childbirth." She argues that by integrating the midwifery model of care with the best that modern medicine has to offer, a woman can have the "best of both worlds."

Dr. Kerr's book begins with a brief explanation of her childbirth philosophies. Next, chapter 2 explains what she means by "homebirth in the hospital." Written specifically for expectant parents, she outlines five essential elements for a successful integrative childbirth: choice, communication, continuity, confidence and trust, and control of protocols. Dr. Kerr supports natural childbirth and encourages women to birth at home or in birth centers if that is what they desire. However, she acknowledges that most women feel safer and more comfortable in a hospital setting and that the empowerment of a home birth can still be experienced in a hospital setting. She writes:

If we combine the two styles, basing our initial care plan on the midwifery model and using the medical technology only when necessary to save lives and to serve the needs of laboring women, we have a true integration: the best of both worlds.

The integrative childbirth model increases patient safety and decreases the physician's risk of liability be creating a strong focus on the individual and her family. Clear communication decreases the risk of litigation by improving patient satisfaction and involving patients in their own care. It is important to remember that technology should never replace experienced human attention during the birthing process.

When the midwifery model is applied, between eighty-five and ninety-five percent of healthy women will safely give birth without surgery or the use of instruments. Medical interventions come into play as part of sensible monitoring during pregnancy, labor, and delivery, but only if they're clearly necessary. In reality, intervention is often inappropriate and may actually be harmful when used purely for convenience or profit.

After these two introductory chapters, the bulk of the book contains fifteen different birth stories, including those of Kerr's two children. Each story is told through the words of the parents. Kerr also offers a brief introduction and commentary to each birth story. Some of these births were with Dr. Kerr, while others were with other integrative family physicians.

Kerr concludes with a chapter written specifically for physicians on how to practice integrative childbirth. This chapter largely repeats what was written in chapter 2. She stresses the same key elements--communication, continuity, confidence and trust, and control of protocols--from a health care provider's point of view. She reminds her physician readers that integrative childbirth is not only safer and more satisfying for the mother; it also can be more rewarding for the physician and, because of the enhanced communication and trust between physician and patient, leads to fewer malpractice suits.

I would recommend this book for pregnant women who are seeking mainstream medical care or who, due to certain circumstances, cannot choose an out-of-hospital birth. It explains how the judicious, rather than routine, use of medical technology is appropriate. For those women already immersed in natural childbirth/midwifery/home birth/unassisted ways of thinking, the book is less useful.

Now for some nit-picking: I do have issues with the phrase "homebirth in the hospital" and with the idea that a hospital birth with an integrative physician is "the best of both worlds." Kerr argues that the key elements of home birth are "satisfaction and empowerment." With that perspective, you can transpose the feeling of a home birth to any location. However, there are other elements of giving birth at home that cannot be transposed to an institutional setting. One could certainly argue that, however satisfying or empowering, a hospital birth can never be a home birth. Not to say that one is inherently superior--just that they are inherently different, and to respect that difference. Some of the best elements of a home birth cannot really exist in a hospital setting, and likewise some of the best parts of modern medicine--especially its strengths at responding to life-threatening emergencies--cannot exist at home. The idea that there is a "best of both worlds" implies that there is an ideal way to approach childbirth, rather than acknowledging that what is best for one woman might be terrible for another.

I also worry that women who read this book may become lulled into a false sense of security that they can "have it all" when, in fact, most physicians do not practice like Dr. Kerr. I know some fabulous family doctors who do, but they are usually rarities in their communities.

Despite these concerns, I am glad that Dr. Kerr has written Homebirth in the Hospital and hope that it will inspire more physicians to adopt integrative medicine. I also hope that it will spur women into thinking more critically and carefully about their maternity care choices.

19 comments:

While I am glad that this gives more mainstream moms a chance to think about their options, I am still very much against low-risk birth in a hospital setting. As you point out, most doctors are not open to this idea. And all the natural-minded philosophy in the world won't protect you from forced procedures or staff who perform procedures or administer medications without consent. The best way to get the birth you want is to stay on your own turf.

I have to admit that the title of the book makes me wrinkle my nose skeptically -- you can't have a homebirth in the hospital, because part of what's so wonderful about homebirth is that you don't leave home and climb in the car at 5cm dilated. You don't drive to the hospital while being pummeled with frequent contractions. You don't have to walk into an unfamiliar building that smells like industrial-strength cleaning products (with faint undertones of disease and death). You don't have to answer question after question posed by strangers who may or may not understand that they shouldn't ask you questions during a giant contraction.

Instead you stay put, in the place where you feel most at ease, and do whatever you need to do to get through labor comfortably. I have found just staying home during active labor to be a powerful analgesic -- my homebirths hardly hurt at all, in sharp contrast to my hospital births.

No matter how committed a given provider may be to assisting women through birth gently and respectfully, there are some things that just don't translate. I believe that part of the debate about out-of-hospital birth safety arises from unfamiliarity on the part of mainstream HCPs with the tremendous qualitative differences between home and hospital birth -- differences that, in my view, go a long way toward explaining why outcomes are comparable. It's very difficult for me to imagine that the feelings of safety and comfort that I experienced with my two homebirths could be portable. Maybe the second printing should be titled "Something Sort of Approximating Homebirth in the Hospital." ;-)

I find it interesting in the debate about homebirth vs. hospital birth that homebirth proponents are so often sure that all women will have a better birth experience at home, just because perhaps they did themselves. Not everyone wants or needs that, but that doesn't mean they shouldn't have minimal intervention and a good relationship with their support team. I agree that a hospital birth is not likely to be the same thing as a home birth, but I think that Dr. Kerr's point is that some women actually ARE more comfortable in a hospital setting. That doesn't necessarily mean that they have to submit to every intervention a hospital might offer. She acknowledges that it's very important to choose a doctor who IS open to this idea- but most importantly, you should choose a doctor or midwife who will support your choices for the birth- whether that's at home or in the hospital.I know this is a heated debate in the larger world, but as a woman who's given birth, I find it refreshing that someone is actually daring to say that a pregnant mother might have some control over who supports her birth regardless of the setting, and that a pregnant mother should not feel that she has to give up one in order get the benefits of the other. Whether we like it or not, sometimes a home birth is simply not an option- and a woman shouldn't be made to feel that she can't have a satisfying birth experience if that's the case. The more of us there are who demand a more personalized level of care for labor and delivery even in the hospital, the better options will be for pregnant women and their support teams everywhere.

Do you think this is a book that should be in my lending library? Would it be something my mostly mainstream clients could read that would give them an idea of how they can be more in control of their labors and births and explain why I don't engage every medical intervention available for every birth?I don't think I'd use the term "homebirth" when describing the births that I attend, but I do try hard to practice with the midwifery model as my guide, and attend a lot of low-intervention births. It might me nice to have some stories for my clients to read that illustrate the types of births they can have even in the hospital.

doctorjen, I think that's an ideal audience for this book- along with health care providers and anyone involved in supporting a birth, no matter where it takes place. It really helped me understand the options available, and provided some valuable advice about navigating those options with my provider.

I had both of my children with midwives in hospitals that claim to provide a home-like atmosphere. Homebirth wasn't something I considered an option with either child for various reasons and I was glad to have halfway option, but I don't think my experience near what having a child at home would be like. With the second child in particular, hospital regulations interfered several times and I was forced to make major concessions to my birth plan even though my midwife didn't consider them medically necessary - all to follow hospital rules as dictated by the attending nurse (who the hospital seemed to have sent to keep the midwives in line). I wouldn't call it approximating a homebirth. More like, "maybe a slightly more pleasant way to give birth in a hospital". I could go on, but thought I'd spare your comments section. If anyone does want details, my email is on my blog...

doctorjen, I think it would be a good one. It gives a basic picture of a variety of births in which the mother was supported in her wishes, was fully aware of her options, and made empowered choices in a hospital settings--sometimes without technology and medications and sometimes with. Like I wrote earlier, I don't think it would really interest someone who already knows a lot about childbirth choices and who has done extensive reading. But, for most women who have little exposure to birth outside mainstream television and "What to Expect," it would be a good introduction to thinking more critically about maternity care and to the variety of options available in a hospital setting.

I'd suggest buying or checking the book out (maybe via ILL?) and seeing what you think. I'd love to hear your thoughts about the utility of the book from a hospital birth attendant's perspective.

Overall the choice of the phrase "homebirth in the hospital" is the book's weakest point. Instead of trying to accomplish something that is fundamentally impossible in a hospital environment, why not simply rename it for what it is? Of course, I can see the utility of the phrase from a marketing perspective...

i wish i knew about this book a few months ago ;o)dh was against homebirth. i was against hospital. i really tried my best to surround myself with people who would lessen the hospital feel. i had a VERY "earthy birthy" midwife and a doula. that helped immensely. my personal beliefs on the subject is that hospitals are for the sick and dying. pathological. not for birth. if you want a more medicalized setting- do a birthcenter.

I was fortunate to have three out of four "homebirths in hospitals" - as close as they could've been - but I definitely see your point, Naomi, about it really not being the same thing; however, I found a physician that basically was there to catch, and that's ALL. She encouraged natural childbirth to all of her patients, ensured the hospital staff knew they were to stay farrrrrrrrrr away from me unless I needed something that *I* asked for, and she showed up to hand the baby to me, per my wishes. I didn't need her there to "help me through".

My first birth was in a military hospital, and is close to the definition of "birth rape" as I've read. I try to forget that experience and focus on the beautiful baby (who's now a teenager - ack!).

That being said, I wish I was at home for all four. I wish I could turn back the clock. I believe I'm safer there - by a longshot. I will encourage my daughters to stay home, I will BEG them if I have to.

I'm looking forward to reading this book for my own knowledge, even though it appears my childbearing years are now passed. Thank you again for the best blog I have in my favorites, Naomi.

I am having problems talking or reviewing anything about birth right now...some delayed ptsd who knows...thus my "birth" blog is so quiet. But this might be something I would like to read. I imagine it to be an eye-opener for lots of readers. But my frustration is still very stalled at the realities of finding these special and rare doctors. Like at our BBBB last year, with all those pregnant Mamas asking us "where do we find a midwife?" I just feel so helpless and hopeless about all of this right now. I have a pregnant friend who is going to one of my former (EVIL) Ob's and even though I dont say anything to "push" my beleiefs on her, even if she were to read this book, what could she do? Where are these "cool" doctors and hospitals?I am so frustrated.Off TOpic perhaps.

I agree Housefairy - the providers (or lack thereof) are part of the problem! I do hope it will push women to understand what a great provider can do for them, and help them find a provider like that, but in some communities that person simply does not exist. Or they are only one in a practice, and you might get whoever's on call that night. In the town where I grew up, the only midwives who practice in the hospital are in a group practice with OBs. Come the day of delivery, you might get any of the midwives OR OBs! I don't really call that a choice.

I know that I am a little late on this post but I just recently came upon this wonderful blog and I thought maybe I would comment here being I have 2 wonderful experiences delivering in the hospital.

Hi my name is Jamie and it has been wonderful reading everyone's comments.

I have 5 children and all of them being hospital births. The 1st 3, my husband and I knew absolutely nothing about pregnancy or birth, we did as what most ladies do now days, we did what the doc said. All 3 being medicated, birthing in bed, and the baby taken away as soon as they were born.

As reading a couple of people that have commented, I too am from Il. I have experienced in and Il hospital 2 wonderful births.

While pregnant with my 4th child my husband and I both had the desire to learn more about birth. I called around trying to find someone to be there for us during a homebirth, being where we live, way out in the middle of no where, we could not find one, so I went to the next best thing, midwife in the hospital.

I called, called, and called, interviewing and meeting with other midwives trying to find the right one. We finally found one 1 hr away and she is GREAT. She left us alone while laboring. The hospital is one of 2 in the state of IL that is baby friendly, after delivering, the hospital staff did NOTHING with both of the babies until we asked. My first child was not weighed, measured, or touched for 5 hours. Second it was 6 and a half. They leave you and the baby for hands on and alone time.

As for refusing anything, I had no problem at all. I had told my midwife what I wanted and what I did not and that was that. Although my husband and I would still love to experience a homebirth someday, I would not be disappointing to have another hospital birth as long it is with the midwife that the Lord has given me.

* NOTE * I would like to throw in that my midwife had homebirths with her children and that she has a desire to help women that want as much as a homebirth in the hospital setting as possible.

Yes her name does start with an A she is the best midwife I could have asked for. We did have the chance to do a homebirth with my last child ( I just had him in Dec ) but we chose to stay with A because of the great experience we had with her. We have decided to stay with her with any future babies, praying that one day she will start delivering at home.